This document summarizes two clinical cases where minimally invasive antral membrane balloon elevation was used to perform sinus lift procedures for single tooth implant placement in the posterior maxilla with reduced bone height. In both cases, the procedure allowed for sufficient bone augmentation to subsequently place dental implants. The procedure was found to be a relatively simple and safe method for rehabilitation of missing teeth in the challenging posterior maxilla, avoiding the need for more invasive sinus lift surgeries.

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Consequently, many clinicians opt to
avoid rehabilitation of a single tooth or
choose as an alternative a three-unit par-
tial denture. While the former may result in
overeruption of antagonist teeth or drifting
of the adjacent ones, the latter may require
irreversible changes to the anatomy and
structure of the abutment teeth. In cer-
tain cases in which the distal and mesial
teeth are already restored with crowns, a
three-unit partial denture may provide an
adequate solution.
Recently, a minimally invasive method
of sinus lift (using an upward expand-
ing balloon deployed via a 3-mm oste-
otomy), minimal invasive antral membrane
balloon elevation,1
was introduced to per-
form posterior maxilla bone augmentation
in even the most challenging subset of
patients.2
In the recently published multi-
center registry3
executed by dentists and
periodontists trained in this procedure, 26
cases (23% of the study cohort) underwent
single-tooth bone augmentation followed
by single implant placement. We present
two demonstrative cases in which minimal
invasive antral membrane balloon elevation
was employed in such clinical settings and
was followed by bone grafting and implant
placement.
The replacement of an individual missing
tooth (second premolar or first or second
molar) in an atrophic segment of the posterior
maxilla presents a considerable challenge.
Open sinus floor elevation (lateral maxillary
window or hinge osteotomy) is frequently
avoided due to its invasive nature and ana-
tomic restrictions such as the roots of adja-
cent teeth, reduced vision, and access to the
sinus cavity within the operative field. The
alternative option, the osteotome technique,
results in only modest bone augmentation
and therefore requires a minimal amount of
pre-existing bone height that is not always
present. Moreover, the manipulation of the
osteotome may be limited, especially in the
second molar area, and extremely difficult in
patients with reduced mouth opening.
1Private Practice, Petah-Tikvah, Israel.
2Private Practice, Rehovot, Israel.
3Director, Department of Interventional Cardiology, University
Hospital, University of Medicine and Dentistry of New Jersey,
Newark, New Jersey, USA.
4Periodontic Clinic, Ra’anana, Israel.
5The Faculty of Dental Medicine, Hadassah - Hebrew University
Medical Center, Jerusalem, Israel; Private Practice of
Periodontics, Tel-Aviv, Israel.
Correspondence: Dr Edo Kaluski, UMDNJ, 185 South Orange
Ave, MSB I-538, Newark, NJ 07103. Email: ekaluski@gmail.com,
kalusked@umdnj.edu
Minimally invasive antral membrane balloon
elevation for single-tooth implant placement
Efraim Kfir, DMD1
/Vered Kfir, DMD2
/Edo Kaluski, MD3
/
Ziv Mazor, DMD4
/Moshe Goldstein, DMD5
A single missing tooth in the posterior atrophic maxillary segment poses a therapeutic
challenge. Open sinus lift is not often performed because of anatomical restrictions and
the need for specific surgical skills. The osteotome approach has considerable efficacy
and safety limitations. In many cases, the clinician elects to treat with a three-unit partial
denture or discard any rehabilitation plans. Two cases in which minimal invasive antral
membrane balloon elevation was performed for single-tooth replacement are presented.
This procedure appears to be a relatively simple, highly effective, and safe solution for sin-
gle-tooth, implant-supported restorations of the posterior atrophic maxilla. (Quintessence
Int 2011;42:645–650)
Key words: antral membrane, bone augmentation, implants, maxilla, maxillary sinus

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Kfir et al
Fig 1a to 1d (a) Preoperative CT; 4 mm of residual bone height from
the alveolar crest to the sinus floor in the area of the missing maxillary
left first molar (site of tooth 26). (b) Minimal flap elevation and oste-
otomy preparation. (c) Balloon harboring device in the osteotomy. (d)
Periapical radiograph of the balloon harboring device during inflation
and Schneiderian membrane elevation. The bone-replacement material
(Bio-Oss, Geistlich-Pharma) was inserted after removal of the balloon.
Fig 1e to 1g (e) CT scan 4 months after the bone augmenta-
tion procedure. Uniform bone level was approximately 6 mm
above the initial bone level, and condensed bone was present in
the osteotomy core. (f) Radiograph of the implant (Biomet 3i).
(g) Final radiograph after crown preparation. The implant was
loaded 4 months after placement.
a
b
c
d
e
f
g

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Case Report
Patient 1
A 45-year-old man was referred to our clinic
for an implant to replace the missing maxil-
lary left first molar (tooth 26). The patient
was otherwise healthy and had no other
dental pathologies. A computed tomogra-
phy (CT) scan revealed reduced vertical
bone height between the alveolar crest and
maxillary sinus floor (Fig 1a).
In consideration of the reduced vestibu-
lar depth and difficult access, it was decid-
ed to augment the sinus floor by employing
the minimally invasive balloon elevation
technique (Figs 1b to 1d). Since the existing
alveolar bone was soft and did not provide
sufficient initial stability for implant place-
ment, the clinician opted for the two-stage
approach, and the implant was placed 4
months after the augmentation procedure
(Figs 1e to 1g).
Patient 2
A 69-year-old man with a missing maxillary
left first molar (site of tooth 26) presented
with the chief complaint of difficult mastica-
tion related to the absent tooth. He had no
known medical problems and was not a
smoker. During the clinical examination, the
patient demonstrated limited mouth open-
ing and therefore difficult access to the
molar area. Upon evaluation of the CT scan
(Fig 2a), it was noted that there was only
4 mm of residual ridge between the sinus
floor and alveolar crest.
The patient underwent minimally inva-
sive antral membrane elevation followed by
bone graft injection (Figs 2b to 2d). Since
primary stabilization was possible due to
the residual bone density, simultaneous
bone grafting and implant placement (Fig
2e) were performed at the same time.
Discussion
This article presents two cases (out of
numerous cases performed by the authors
and other clinicians) in which bone aug-
mentation and single-tooth implant place-
ment in the atrophic posterior maxilla was
performed employing minimally invasive
antral membrane balloon elevation.
Preprocedural CTs and panoramic
and periapical radiographs are obtained
to assess mucosa thickness, pathology,
bone height and thickness, sinus structure,
and major blood vessels. Preprocedural
nonsteroidal anti-inflammatory agent and
Augmentin (Amoxicillin Clavulanate) 875
mg twice daily were initiated 24 hours prior
to the procedure. To obtain platelet-rich
fibrin, 40 to 80 mL of the patient‘s blood was
drawn by venous puncture and processed.
The procedure was performed under local
anesthesia: Horizontal full thickness flap
with palatal bias (to preserve keratinized
tissue) was followed by two small vertical
incisions to expose the alveolar crest. Initial
pilot drilling (2-mm diameter handpiece) at
the center of the alveolar crest up to 1 mm
underneath the sinus floor is enlarged to
2.9 mm with a dedicated osteotom. Bone
graft material (Mineross, Biohorizons) is
injected into the osteotomy, and the sinus
floor is gently fractured with the osteotom.
After removing the osteotome, the mem-
brane integrity is assessed (by Valsalva
maneuver). Additional bone graft material is
injected into the osteotomy, and a dedicat-
ed screw-tap is tapped into the osteotomy
1 mm beyond the sinus floor. After screw-
tap removal and sinus membrane integrity
evaluation, the metal sleeve of the balloon-
harboring device is inserted into the oste-
otomy 1 mm beyond the sinus floor. The
balloon is inflated slowly with the barometric
inflator up to 2 atmospheres. Once the bal-
loon emerges from the metal sleeve and
expands underneath the sinus membrane,
the pressure drops to 0.5 atmospheres.
Subsequently, the balloon is inflated with
progressively higher volume of contrast
fluid. The balloon inflation and membrane
elevation are evaluated by sequential peri-
apical radiographs. Once the desired ele-
vation (10 to 16 mm height) was obtained,
the balloon was left inflated ≥ 5 minutes (to
reduce the sinus membrane recoil). The
balloon was then deflated and removed.
The membrane integrity is reassessed by
direct visualization and examination with the
suction syringe and respiratory movement
of blood within the osteotomy.

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Using a bone graft injector, a mix of
bone substitute, platelet-rich fibrin, and
autologous bone particles (collected by
suction filter during drilling and bone from
the tuberosity) are injected through the
osteotomy underneath the antral mem-
brane. Bone grafting is followed by implants
(3.75 to 5.00 mm diameter), placement, and
primary closure.
Fig 2e Periapical radiograph at the end of the
procedure. Uniform filling of the augmented
area can be observed surrounding the 13-mm
implant (High-tech).Fig 2d Periapical radiograph of the balloon harboring
device during inflation and antral membrane elevation.
The bone replacement material (Mineross, Osteotech)
was inserted immediately after removal of the balloon.
Fig 2a to 2c Preoperative CT of the missing maxillary left first molar area.
There was 4 mm of relatively dense residual bone from the alveolar crest to the
sinus floor. (b) Minimal flap elevation. Osteotomy preparation according to the
minimally invasive antral membrane balloon elevation protocol.1 (c) Balloon
harboring device in the osteotomy. The mouth opening limitations of the
patient were overcome due to the size and flexibility of the minimally invasive
antral membrane balloon elevation device.
a
b
c

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Patients are discharged with ibuprofen
600 mg (single dose) for pain relief and
Augmentin 875 mg twice daily for 7 days.
Suture removal is executed within 7 days.
At 6 months follow-up, CT and periapical
radiographs are performed and prosthet-
ic rehabilitation is initiated 3 weeks after
implant exposure.
The results of minimally invasive antral
membrane balloon elevation were evaluat-
ed in a multicenter registry of 112 consecu-
tive procedures, executed predominantly
(85%) by clinicians after abbreviated train-
ing and supervision (Table 1). The results of
the registry were formerly published.3
This procedure has several advantages.
It is brief (less than 60 minutes), performed
under local anesthesia, and leaves the
patient with very little operative and postop-
erative discomfort.
Although this procedure is minimally
invasive, it can be applied to the vast
majority of patient subsets and practically
all maxillary and sinus pathology variants,
with 97.3% procedural success.3
Moreover,
the procedure can be accomplished in
outpatient settings, requires considerably
less surgical skill than the lateral window,
and has outstanding efficacy and safety
record (consistent incremental bone height
8 mm and 95% implant survival).3
In 98%
of the cases listed in the registry, implants
were placed immediately after the sinus
lift and bone augmentation. Complications
are negligible and mostly limited to minimal
(8%) and major (2.7%)3
membrane tears.
(Only the latter require discontinuation of
the procedure but does not reduce the
success rate of a repeat procedure within
1 month.)
The lateral maxillary window has been
the most widely employed method for
maxillary bone augmentation. Besides the
requirement of high surgical expertise and
surgical tools and equipment, it is relatively
contraindicated in certain patient subsets
(sinus convolution or septum, narrow sinus,
or previous sinus surgery) and is associ-
ated with unique complications (besides
membrane tear, bleeding, infection, nerve
laceration, and sinus obstruction) and con-
siderable patient discomfort and swelling.
It offers robust bone augmentation with
implant survival ranging from 61.7% to
100%.4
The osteotom technique, while truly min-
imally invasive, has limited applicability
and efficacy5
(not suitable for patients with
Table 1 Results of 112 procedures in the multicenter registry3
No. %
Efficacy
Primary procedural (successful initial procedure) 109 97.3
Secondary success (successful initial or second procedure) 112 100.0
Initial bone height (mm) 3.8 ± 2.1 —
Range of bone incremental height (mm) 11–18 mm —
Implant survival at 6 mo 208/219 94.9
Number of 0/1/2/3 implants inserted per case 2/26/59/25 1.8/23.2/52.6/22.3
Procedure time (including implant placement) (min) 58 ± 23 —
Safety
Major complications: Infection with oroantral fistula at 4 wk 1 0.9
Minor complications: Membrane tear requiring procedure
discontinuation and second procedure
3 2.7
Nuisance complications: Minimal membrane tear sealed by
platelet rich fibrin
9 8.0

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markedly reduced bone height6
) and even
in the best of hands with specialized instru-
ments7
still results in high rate of membrane
tear.8
One of the distinct advantages of mini-
mally invasive antral membrane balloon
elevation is the possibility to safely perform
sinus membrane elevation and bone aug-
mentations in sites that are anatomically
difficult to access.
It is likely that once mastered by den-
tists, this procedure will reduce treatment
barriers related to risk benefit ratio, cost,
and discomfort. Due to its superb bone
augmentation efficacy (especially when
compared to the limited incremental bone
height and augmentation efficacy obtained
with the osteotom technique9), outstanding
safety and patient acceptance (compared
with open procedures10,11
), and its uniform
applicability, it should become the pre-
ferred method for single-tooth bone aug-
mentation and implant placement.
Conclusion
There is a definite need to make the reha-
bilitation of single missing teeth in the
atrophic posterior maxilla segment a more
acceptable procedure for practitioners and
patients alike to overcome the treatment
barriers associated with current open surgi-
cal methods. The minimally invasive antral
membrane balloon elevation has the poten-
tial to provide the tools to achieve this goal.
Acknowledgments
This study was self-funded (no external funding, apart
from the support of the authors‘ institutions, was avail-
able for this study). Dr Efraim Kfir is the inventor, founder,
and CEO of MIAMBE. Dr Vered Kfir is his wife. Drs
Goldstein, Mazor, and Kaluski are consultants to MIAMBE
and also hold equity in the company.
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